Management of irreparable subscapularis tendon tears [Elektronische Ressource] / von Ariane Gerber Popp

-

Documents
107 pages
Obtenez un accès à la bibliothèque pour le consulter en ligne
En savoir plus

Description

MANAGEMENT OF IRREPARABLE SUBSCAPULARIS TENDON TEARS Habilitationsschrift zur Erlangung der Lehrbefähigung für das Fach Orthopädie vorgelegt der Medizinischen Fakultät der Charité - Universitätsmedizin Berlin von Dr. med. Ariane Gerber Popp geboren am 7. Juli 1965 in Porrentruy, Schweiz Dekane: Prof. Dr. med. J. W. Dudenhausen Prof. Dr. med. M. Paul Eingereicht: April/ 2004 Öffentlich-wissenschaftlicher Vortrag am: 21. November 2004 Gutachter: 1. Prof. Dr. med. A. Imhoff, München 2. Prof. Dr. med. P. Hoffmeyer, Genf EIDESSTATTLICHE VERSICHERUNG gemäß Habilitationsordnung der Medizinischen Fakultät Charité Hiermit erkläre ich, daß - keine staatsanwaltschaftlichen Ermittlungsverfahren gegen mich anhängig sind, - weder früher noch gleichzeitig ein Habilitationsverfahren durchgeführt oder angemeldet wurde bzw. welchen Ausgang ein durchgeführtes Habilitationsverfahren hatte; - die vorgelegte Habilitationsschrift ohne fremde Hilfe verfaßt, die beschriebenen Ergebnisse selbst gewonnen wurden, sowie die verwendeten Hilfsmittel, die Zusammenarbeit mit anderen Wissenschaftlerinnen oder Wissenschaftlern und technischen Hilfskräften und die Literatur vollständig angegeben sind, - mir die geltende Habilitationsordnung bekannt ist. Datum Unterschrift 2CONTENTS 1 INTRODUCTION 7 1.

Sujets

Informations

Publié par
Publié le 01 janvier 2004
Nombre de visites sur la page 69
Langue Deutsch
Signaler un problème

MANAGEMENT OF IRREPARABLE SUBSCAPULARIS TENDON TEARS


Habilitationsschrift
zur Erlangung der Lehrbefähigung
für das Fach


Orthopädie



vorgelegt der Medizinischen Fakultät der Charité - Universitätsmedizin Berlin



von

Dr. med. Ariane Gerber Popp

geboren am 7. Juli 1965 in Porrentruy, Schweiz





Dekane:

Prof. Dr. med. J. W. Dudenhausen
Prof. Dr. med. M. Paul



Eingereicht: April/ 2004

Öffentlich-wissenschaftlicher Vortrag am: 21. November 2004


Gutachter:


1. Prof. Dr. med. A. Imhoff, München


2. Prof. Dr. med. P. Hoffmeyer, Genf
EIDESSTATTLICHE VERSICHERUNG

gemäß Habilitationsordnung der Medizinischen Fakultät Charité



Hiermit erkläre ich, daß

- keine staatsanwaltschaftlichen Ermittlungsverfahren gegen mich anhängig sind,

- weder früher noch gleichzeitig ein Habilitationsverfahren durchgeführt oder
angemeldet wurde bzw. welchen Ausgang ein durchgeführtes Habilitationsverfahren
hatte;

- die vorgelegte Habilitationsschrift ohne fremde Hilfe verfaßt, die beschriebenen
Ergebnisse selbst gewonnen wurden, sowie die verwendeten Hilfsmittel, die
Zusammenarbeit mit anderen Wissenschaftlerinnen oder Wissenschaftlern und
technischen Hilfskräften und die Literatur vollständig angegeben sind,

- mir die geltende Habilitationsordnung bekannt ist.








Datum Unterschrift



2CONTENTS
1 INTRODUCTION 7
1.1 IRREPARABLE ROTATOR CUFF TEARS: DEFINITIONS AND THERAPEUTICAL PRINCIPLES 8
1.1.1 FATTY DEGENERATION AND ATROPHY OF THE ROTATOR CUFF MUSCLES 8
1.1.2 PATTERNS OF CHRONIC ROTATOR CUFF TEARS 9
1.1.3 SURGICAL APPROACHES TO IRREPARABLE ROTATOR CUFF LESIONS 11

1.2 STRUCTURAL FUNDAMENTALS OF SKELETAL MUSCLE 13
1.2.1 STRUCTURAL MODELS 13
1.2.2 CONTRACTILE MECHANISM 14
1.2.3 RELEVANCE OF MUSCLE CAPABILITIES IN TENDON TRANSFER SURGERY 19

1.3 TENDON TRANSFER PROCEDURES AROUND THE SHOULDER 22
1.3.1 OVERVIEW ON CLINICAL EXPERIENCE 22
1.3.2 TENDON TRANSFER PROCEDURES FOR IRREPARABLE SUBSCAPULARIS AND
ANTEROSUPERIOR TEARS 24

1.4 SCIENTIFIC OBJECTIVES OF THE MONOGRAPH 25

1.5 REFERENCES 26
2 ANATOMY 34
2.1 THE SUBSCAPULAR NERVES ARE ANATOMICAL CONSTRAINTS TO CIRCUMFERENTIAL
RELEASE OF THE SUBSCAPULARIS MUSCLE 35
2.1.1 INTRODUCTION 35
2.1.2 MATERIAL AND METHODS 36
2.1.3 RESULTS 37
2.1.4 DISCUSSION 41
2.1.5 REFERENCES 43

2.2 SELECTIVE RECONSTRUCTION OF THE LOWER SUBSCAPULARIS WITH THE TERES MAJOR.
ANATOMICAL BASIS FOR A NEW TENDON TRANSFER 44
2.2.1 INTRODUCTION 44
2.2.2 MATERIAL AND METHODS 45
2.2.3 RESULTS 46
2.2.3.1 Vascular supply 46
2.2.3.2 Neural supply 48
2.2.3.3 Description of the latissimus dorsi and teres major tendons 48
2.2.3.4 Transfer of the teres major to the lesser tuberosity 50
2.2.4 DISCUSSION 51
2.2.5 REFERENCES 53

3
3 BIOMECHANICS 54
3.1 THREE-DIMENSIONAL ANATOMY OF THE ROTATOR CUFF 55
3.1.1 INTRODUCTION 55
3.1.2 MATERIAL AND METHODS 56
3.1.2.1 Specimen preparation 56
3.1.2.2 Data collection 60
3.1.2.3 Computer modelling and calculation 61
3.1.3 RESULTS 64
3.1.4 DISCUSSION 65
3.1.5 REFERENCES 66

3.2 TENDON TRANSFER PROCEDURES FOR IRREPARABLE SUBSCAPULARIS TEARS. A THREE-
DIMENSIONAL VECTOR ANALYSIS 68
3.2.1 INTRODUCTION 68
3.2.2 MATERIAL AND METHODS 69
3.2.2.1 Specimen preparation 69
3.2.2.2 Data collection, modelling and calculation 69
3.2.3 RESULTS 70
3.2.3.1 Pectoralis major transfer according to Wirth and Rockwood (PM-I) 70
3.2.3.2 Pectoralis major transfer by Warner (PM-II) 72
3.2.3.3 ansfer by Resch (PM-III) 73
3.2.3.4 Combined teres major-split pectoralis major transfer (TM-sPM transfer) 73
3.2.4 DISCUSSION 75
3.2.5 REFERENCES 76
4 CLINICAL APPLICATIONS 77
4.1 THE COMBINED TERES MAJOR AND SPILT PECTORALIS MAJOR TRANSFER FOR SELECTIVE
RECONSTRUCTION OF IRREPARABLE SUBSCAPULARIS TEARS 78
4.1.1 INTRODUCTION 78
4.1.2 MATERIAL AND METHODS 79
4.1.2.1 Concept of selective subscapularis reconstruction 79
4.1.2.2 Patients 80
4.1.2.3 Structural lesions, indication for transfer surgery 81
4.1.2.4 Surgical technique 82
4.1.2.5 Evaluation 89
4.1.3 RESULTS 90
4.1.3.1 Clinical outcome 90
4.1.3.2 Radiographic outcome 91
4.1.3.3 Complications 91
4.1.4 DISCUSSION 92
4.1.5 REFERENCES 94

4
5 CONCLUSIONS 97
REFERENCES 99
ACKNOWLEDGEMENTS 106
5















I grew up with an ambition and determination without which I would have been a good deal
happier. I thought a lot and developed the far-away look of a dreamer, for it was always the
distant heights which fascinated me and drew me to them in spirit. I was not sure what could
be accomplished by means of tenacity and little else, but the target was set high and each
rebuff only saw me more determined to see at least one major dream through to its fulfillment.

Earl Denman, Alone to Everest
6
1 INTRODUCTION

The first description of an isolated subscapularis tendon tear is attributed to Gerber and
1Krushell. The authors noted that clinical diagnosis of subsapularis tears remains a challenge
and they described the so-called lift-off sign as a reliable clinical sign for the diagnosis of
subscapularis insufficiency. In a subsequent follow-up of his experience Gerber reported on
the midterm results after repair of the subscapularis tendon. He observed that repairs of
chronic subscapularis tears had a much poorer outcome than repairs performed in an acute
2setting.
The anterosuperior cuff tear configuration, which represents a tear of the subscapularis in
combination with the supraspinatus and sometimes the infraspinatus, was first recognized as
3a discrete entity by Warner et al. . The authors observed, in the same way as Gerber, that
tears involving the subscapularis often had a delayed diagnosis which resulted in late
presentation of the patients for treatment.
Indication for reconstruction of chronic subscapularis tears by tendon tranfer are not yet fully
established. All considerations must be placed in the context of the patients disability and their
expectations for pain relief and functional recovery. Many factors like location of the tear,
quality of the tendon tissue to repair, associated degenerative changes of the glenohumeral
joint, number and nature of previous surgeries, age and compliance of the patient should be
considered prior surgery. As this tear configuration occurs usually in younger and active
patients, treatment in the chronic situation after delayed diagnosis is challenging, because
recovery of function and strength is essential in this high demanding group of patients.

71.1 IRREPARABLE ROTATOR CUFF TEARS: DEFINITIONS AND THERAPEUTICAL PRINCIPLES
1.1.1 FATTY DEGENERATION AND ATROPHY OF THE ROTATOR CUFF MUSCLES
4-6Structural integrity of the rotator cuff is a conditio sine qua non for normal shoulder function.
7,8Although clinical results after repair of massive rotator cuff tears are frequently good ,
several studies have shown that structural healing does not reliably occur after technically
4,5,9successful repair of massive tears.
During many years the principles in diagnosis and treatment of rotator cuff tears had focused
on the tendinous defect and its reattachment to the bone only, without considering the effect
of the tendon tear on the corresponding muscle.
The correlation between rotator cuff tear and a possible degeneration of the affected muscles,
10was described by Goutallier et al., 1989. Based on standardized preoperative CT scan
images of the shoulder of patients undergoing rotator cuff surgery, he defined a rating system
describing a muscular degeneration of torn rotator cuff units. Histologically the degeneration
was shown to correspond to an infiltration of the muscular substance by fat, the so called fatty
11degeneration. The comparable observations were made in a rabbit model.
Another feature of the torn rotator cuff muscle, namely muscle atrophy, has been described
12on MRI by Nakagaki. Zanetti et al. demonstrated that the degree of atrophy measured on
cross-sectional aeras of standardized para-sagittal MRI images inversly correlates to the
13degree of fatty degeneration.
Both fatty degeneration and atrophy have been shown to be an irreversible process in the
9,14,15animal and in humans after successfull structural repair of the tendon. Furthermore,
Gerber et al. demonstrated in a clinical study that degenerative muscular changes even may
increase after repair suggesting that high tension resulting from reinsertion of a less elastic
9musculotendinous unit may worsen the state of degeneration of the affected muscle.
8Due to the irreversible loss of contractile properties of the repaired musculotendinous unit,
weakness persists even after structural repair of the tendon. Furthermore advanced atrophy
and fatty degeneration has been shown to be more often associated with retear when primary
9,16repair is attempted. Up to now no scientific data are available, defining precisely at which
stage of muscular degeneration and in which part of the rotator cuff primary repair of a torn
tendon is still possibly. However clinical experience suggests that in the presence of fatty
degeneration higher than Grade II according to Goutallier, an alternative to primary tendon
repair should be considered, especially if recovery of function and strength is the goal of
treatment.
Those observations have fundamentally changed the way to evaluate and treat rotator cuff
tears in the last years. A rotator cuff tear is no longer an isolated tendinous pathology, but
much more a disease of the whole musculotendinous unit. This is of utmost importance when
surgical treatment is considered.
1.1.2 PATTERNS OF CHRONIC ROTATOR CUFF TEARS
Reparability

Rotator cuff tears involving two tendons or more are defined as massive tears. They are
commonly associated with muscle atrophy and fatty degeneration of the corresponding
muscles, leading to decrease in contractile properties of the musculotendinous units. As
advanced atrophy and fatty degeneration appears to be irreversible and often associated with
retear when primary repair is attempted, such tears are considered irreparable.
In rare cases, the quality of the tendon is so poor, even in absence of advanced degenerative
changes of the muscle, that secure repair to the bone is not possible. Such tears are
encountered in revision surgery and are also considered irreparable.


9Configurations of irreparable rotator cuff tears

Irreparable chronic rotator cuff tears can be divided into several patterns showing a different
epidemiology, associated disability and natural history.
Because they are small and do not tend to retract, isolated supraspinatus tears can usually
be repaired reliably. In rare cases fatty degeneration and atrophy of the supraspinatus muscle
and/or poor tendon quality can render a tear irreparable. As the remaining parts of the cuff are
intact, the functional deficit remains moderate. Pain and decrease in abduction strength are
the leading symptoms.
Disruption of the infraspinatus is always associated with a supraspinatus tear and has been
defined as posterior-superior tears. Per definitionem those tears are massive involving at least
two tendons, the supraspinatus and infraspinatus, and may extend into the teres minor. In
some patients where the tears extend inferior to the equator of the humeral head, the force
couple between the anterior and posterior part of the cuff is disrupted. The required force to
stabilize and to maintain a fixed fulcrum for rotation of the humeral head in the glenoid during
flexion or abduction is insufficient. Functionally this leads to a superior migration of the
humeral head and a decrease in abduction and flexion. Due to the insufficient infraspinatus,
17the strongest external rotator of the glenohumeral joint, those tears make movement of the
hand to mouth or to the head difficult.

Isolated ruptures of the subscapularis are less frequent than supraspinatus or anteroposterior
rotator cuff tears. Because unspecific complaints like pain and weakness without severe loss
of function are in most cases the only clinical signs, subscapularis tears are underdiagnosed
and treatment mostly occurs with delay. Then reconstruction of the tendon may not be
possible anymore due to fatty degeneration and atrophy of the subscapularis muscle.

10